PPt Donna Zhukovsky- Palliative Care, Part 3- MC-CH · PDF file1 PowerPoint Slides English Text Mandarin Chinese Translation Palliative Care, Part 3 VideoTranscript 3 Professional

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PowerPoint Slides English Text Mandarin Chinese Translation

Palliative Care, Part 3 VideoTranscript

姑息性护理，第 3 部分视频文本

Professional Oncology Education Palliative Care, Part 3 Time: 19:27

专业人员肿瘤学教学讲座姑息性护理，第 3 部分时间： 19:27

Donna S. Zhukovsky, M.D., F.A.C.P., F.A.A.H.P.M. Professor Palliative Care & Rehabilitation Medicine The University of Texas MD Anderson Cancer Center

德克萨斯大学 MD Anderson 癌症中心姑息性护理和复健医学科教授

Donna S. Zhukovsky, M.D., F.A.C.P., F.A.A.H.P.M.

Palliative Care: Part IIIPalliative Care: Part IIIPalliative Care: Part IIIPalliative Care: Part III

Palliative Care: Part IIIPalliative Care: Part III

Donna S. Zhukovsky, M.D., F.A.C.P.,

F.A.A.H.P.M.

Professor

Palliative Care & Rehabilitation Medicine

Welcome to this third module in a series of three about palliative care. My name is Donna Zhukovsky. I am a medical oncologist by training and a palliative care physician at The University of Texas MD Anderson Cancer Center.

欢迎参加姑息性护理系列三部分讲座的第三单元。我叫 Donna Zhukovsky，是德克萨斯大学 MD Anderson 癌症中心接受过培训的肿瘤科医生及姑息性护理医生。

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ObjectivesObjectivesObjectivesObjectives

Upon completion of this module, participants will be able to:

•Describe models of palliative care in the U.S.

•Discuss the role of palliative care throughout the disease trajectory

•Identify key differences between home care and hospice care

•Provide a definition of hospice

•Identify hospice admission criteria

What we’ll be looking at today are describing models of palliative care that are available in the United States; the role of palliative care throughout the disease trajectory, so from the time of diagnosis up and until the time of death and beyond for those people that do succumb to the illness. We’ll identify key differences between home care and hospice and look at the role of hospice care in somewhat more detail, including a definition of hospice used in the United States, as it does vary from country to country. And we’ll look at hospice admin. --- admission criteria in the US.

今天我们要学习的是描述在美国可以使用的姑息性护理模式；姑息性护理在整个疾病发展轨迹中的作用，即从确诊到患者因病去世以及去世之后。我们会确定居家护理和临终关怀的关键不同之处，并且会详细了解临终关怀护理的作用。临终关怀在各国都有不同的定义，我们会讨论美国使用的临终关系定义。我们会探讨在美国的临终关怀录入标准。


Models of Palliative Care in the United States

• Integration throughout the disease trajectory

• Hospital-based models

• Community-based models

• Hospice care

Okay, and in type --- in terms of the different models of palliative care in this country, we have hospital-based models, community-based models, and then hospice care, which is a community-based model of palliative care, one type.

美国姑息性护理的不同模式包括医院模式、社区模式以及临终关怀护理。而临终关怀护理就是一种姑息性护理的社区模式。

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Sheffield Model for ComprehensiveSupportive Care of Life-threatening Disease

From Sheffield Palliative Care Studies Group Annual Review, July 1998-June 1999

Now, what I’d like you to see here, and this is just one model of palliative care derived from the Sheffield model, is that palliative care is not exclusively for the benefit of patients who are dying of a life-threatening illness and their families. But actually can be implemented for people with any life-threatening disease from the time of screening and investigation through diagnosis and through a variety of disease --- types of disease-directed therapies including curative therapies, life-prolonging therapies, life-maintaining therapies, and exclusively supportive therapies. And that the different types of palliative care provided, or supportive care, can include, in addition to palliative care as we have been discussing it in the past two modules of this series, rehabilitation, psychology, social work, and all the other interdisciplinary groups that we can use to support our patients and their families. The reason I pointed out that it extends --- can extend beyond death for those patients that die, is that palliative care, as emphasized previously, is not only for the patient, but for the family. So it continues on into grief and bereavement for those --- the families of those individuals that do die.

这里我想给大家展示的是从 Sheffield 模式衍生的一种姑息性护理模式。姑息性护理的服务对象并不只是即将病逝的患者及其家人，而是可以在不同的阶段服务于身患危及生命的疾病的患者，即从接受筛查和检查、到确诊、接受不同类型的疾病治疗，治疗包括治愈性疗法、延长生命的疗法、维持生命疗法以及仅提供支持的疗法。提供的不同姑息性护理类型或支持性护理，除了本系列前两个单元论及的姑息性护理之外，还可以包括复健、心理、社会工作和可以用来支持患者及其家人的所有其他跨学科小组。我之所以说姑息性护理会延续到患者死亡之后，是因为，如前所述，姑息性护理不仅针对患者，还针对家人，所以会在患者去世之后继续帮助家人面对悲伤与哀丧。

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U.S. Hospital-based Models of Acute Palliative Care

• Primary palliative care– Provided by primary care M.D.’s

– Requires acquisition of knowledge, attitudes and skills

• Secondary palliative care– Consultation services, inpatient units, outpatient clinics

– Palliative care programs available in ~6% of 7,000 surveyed hospitals and in 26% of teaching hospitals

• Tertiary palliative care– For patients with the most complex care needs

– By palliative care specialists in academic medical centers; research and education an integral component

von Gunten CF. JAMA 2002 287(7):875

Now, the information that I have on this slide is taken from an article in JAMA back in 2002 and while some of the numbers may have changed, I think the definitions are important. So, in terms of US hospital-based models of palliative care, we have primary palliative care, secondary, and tertiary. Primary palliative care is really provided by primary physicians, be it a family practitioner, an internist; for people that have cancer, it could be the oncologist; people with dementia may be the geriatrician or the neurologist. And so, it’s basic types --- basic types of palliative care, symptom assessment and man --- management, understanding the role that the different domains play to symptom expression. And it requires that that primary type physician have knowledge, attitudes, and skills. So, often we find that primary physicians, and some of these may be specialists, but the primary provider for that particular illness, that individual may not have received training in the requisite areas for the provision of primary palliative care and that there may be barriers to such in terms of attitudes or acquisition of competency. And that’s been, I’m happy to say, been changing over the past several years, as these skills have been integrated into nursing, physician, physician assistant, social work curricula throughout the country. Secondary palliative care typically is provided as a consultation service. It can be in inpatient units, outpatient clinics, but it’s typically more of a consultation service, so that if the primary ser --- provider is unable to provide that particular expert --- expertise, they refer out. Now, at the time this article was published in 2002, there were palliative care programs available in 6% of the 7000 surveyed hospitals and in about a quarter of teaching hospitals. I was at the Academy --- American Academy of Hospice and Palliative Medicine Annual Scientific Meeting last year and I am happy to say that those numbers have increased. And, for example, a quarter of academic centers now have palliative care programs.

这张幻灯片上的信息来自 2002 年 JAMA 上的一篇论文。尽管其中的某些数字可能已经发生了变化，但我觉得其中的定义非常重要。美国医院的姑息性护理模式分为主要、次要和三级姑息性护理。主要姑息性护理实际上是由基础保健医生提供的。基础保健医生可以是家庭医生、内科医生；如果是癌症患者，则可以是肿瘤科医生；如果是痴呆患者，则可以是老年病科医生或神经科医生。这些是在理解了不同领域对症状表述的作用后，对姑息性护理、症状评估与管理的基本分类。主要姑息性护理类型的医生必须有相关的知识、态度与技巧。基础保健医生，其中可能有提供特定疾病基础保健服务的专科医生，他们可能没有接受过提供主要姑息性护理所必需的培训，这样就可能在态度或能力方面存在障碍。而随着相关技能被纳入全美的护理、医生、医生助理、社工等教育课程，这一状况在过去几年出现了令人欣喜的变化。次要姑息性护理一般是通过会诊服务提供。次要姑息性护理可以发生在住院病房、门诊诊所，但更多是会诊服务。这样如果基础保健医生不具有特定专业经验，可以转介患者。在本篇论文于 2002 年发表时，7000 家接受调查的医院中有 6%，教学医院中大概有四分之一，提供有姑息性护理计划。我去年参加了美国临终关怀和姑息性医学协会年度科学大会，可以很高兴地告诉大家这些数字都有了上升。例如，现在四分之一的学术

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Now, tertiary palliative care is for the patients with the most complex care needs, so again typically assumes a referral --- or presumes --- I should say. It’s by palliative care specialists --- it is provided by palliative care specialists in academic medical centers. But what makes this --- in addition --- tertiary palliative care is that in addition to the provision of clinical care in these centers, research and education is an integral component of what they do. So, this is what leads to the next generation of palliative care specialists in whichever discipline and also helps develop and support, expand the evidence base for what we do in palliative care, so again, an --- an important component of palliative care.

中心都有姑息性护理课程。三级姑息性护理是针对护理需求最为复杂的患者，所以一般需要转介。三级姑息性护理是由姑息性护理专家在学术性医学中心提供。三级姑息性护理除了在这些中心提供临床护理之外，研究与教学也是其必不可少的组成部分。所以三级姑息性护理是培养各学科下一代的姑息性护理专家，而且帮助开发、支持和扩展姑息性护理的证据资料库。所以说三级姑息性护理是姑息性护理的重要组成部分。


Community-based Palliative Care

• Outpatient visits

• Skilled home care

• Hospice

Now, if we would look at what’s available in the community, there are outpatient visits; so, the traditional healthcare model in this country where people come back and forth to see the physician in his or her office. We can provide skilled home care through nursing services and then there are hospice care. And I’ll be delineating the differences between them.

社区可以提供的服务包括门诊就诊，即美国传统的保健模式，患者前往医生诊所就诊；可以通过护理服务机构提供专业的居家护理，然后还有临终关怀护理。我会介绍这之间的区别。

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Traditional Home Care

• Curative or restorative goal of care

• Admission criteria: skilled need, homebound

• Focused on patient

• Visit frequency and services determined by medical provider

• Fee for service reimbursement model

Now, traditional home care again provided by skilled nursing service. For this --- for this type of care typically the goal is that it’s curative or restorative. So once the need resolves, home care’s gone. So, if somebody has the need for home IV antibiotics, it’s a self-limited period of time. If somebody comes home with a new tracheostomy or a new colostomy, home care may be there, but only until the family or patient learn how to provide that type of care themself. Admission criteria are such that there must be a skilled need, so it must --- so there must be a requirement for skilled nursing and that the patient be homebound. And so, for example, people who are getting home care other than to go see their physician in the outpatient office really are restricted to home. They can’t go out shopping. They can’t go out for tea. They can’t go to the movies. Services are focused on the patient, not --- the unit of care is not the patient and family. And it’s a pretty hierarchical service wherein that the visit frequency and services are determined by the medical provider. And typically this falls into a fee for service model.

传统居家护理是由专业护理服务机构提供的。此类护理的目标通常是治愈或康复。一旦不再有这样的需要，则不再提供居家护理。所以如果某位患者需要在家中静脉注射抗生素，那么服务时间仅限于注射所需时间。如果某位患者在新接受了气管切开术或结肠造口术后返回家中，则会提供居家护理服务，一旦家人或患者本人掌握如何自己进行这类护理后即告停止。录入标准是必须具备对专业护理的需求，而且患者必须休病在家，比如说接受居家护理而不去门诊看医生的患者。他们不能出门购物，不能出门喝茶，不能去看电影。提供的服务是针对患者本人，而不是患者兼家人。这是等级服务，也就是说家访的频率和提供的服务类型由医疗服务提供者确定。而且通常是按照服务收取费用。

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Hospice

A Concept of Care

Not a Place of Care

Now, hospice is a concept of care. It’s not a place of care. And, common --- commonly, what I’ll hear is that people go to hospice. So often people mistakenly think that patients on hospice are cared for in an inpatient setting. And, in fact, by Medicare criteria, 80% of patient care provided by a given hospice in an assessment period takes place in the home setting, in the residential setting. So, it’s a concept of care and not a place of care; where care is focused on quality of life for people who can no longer benefit from cur --- curative therapy, where they’ve exhausted those options.

临终关怀是一种护理概念，而非提供护理的地点。人们通常说某人去了临终关怀。所以人们常常误以为接受临终关怀的人是住院接受护理。而实际上，按照

Medicare 的标准，在评估时间内，特定临终关怀机构的患者照护有 80% 是在家、在居家环境中提供的。所以临终关怀是一种护理的概念，而不是护理地点；护理侧重的是患者的生活质量，这些患者已经接受了各类治愈性疗法，而不再能够从中获益。


Medicare Certified Hospice Admission Criteria

• Dual physician certification of life expectancy < 6 months

• Service with non-curative intent

• Primary caregiver availability

It requires dual physician certification of a life expectancy of six months or less if the disease runs its anticipated course. And this is often a deal breaker, because physicians are often concerned about suggesting hospice care because, to the patient, it means they are dying. And it’s a hard thing to --- to bring up. It’s a hard thing to sign the hospice consent papers. But, I think, we need to emphasize here that it’s if the disease runs its expected course. Because even Medicare, and the guidelines were formulated by Medicare, recognizes that clinicians don’t have a crystal ball and so we’re often not very accurate at certifying prognosis. So as long as there is, you know, in good faith, life expectancy of six months or less, if the disease runs its expected course. And, if the patient meets ris --- re-certification criteria and those vary at each reassessment period. And those assessment criteria --- re-certification criteria, vary depending on the hospice qualifying diagnosis. But basically, they show decline. So people can actually continue on hospice for much longer than six months as long as they meet the

接受临终关怀必须具备两位医生开具的证明，说明如果疾病照常进展，患者的预期寿命将不超过六个月。这常常会让事情变得棘手，因为提议接受临床关怀护理对患者来说意味着他们将不久于人世。所以医生常常会心存顾虑，开口难，签署临终关怀同意文件也难。但我认为，这时我们需要强调，是假设疾病正常进展。因为即使是 Medicare 指定的指南也承认临床医生并没有预知未来的能力，我们在确定预后方面常常不是那么精确。所以六个月的预期寿命是根据疾病正常进展做出的诚实推断。如果患者符合重新认证标准，则在每个重新评估期都会有所不同。这些重新认证标准取决于临终关怀资格诊断的具体情况，但基本上显示情况恶化。所以患者实际上接受临终关怀的持

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criteria. It does imply service with noncurative intent. And it does require primary caregiver availability. But, again, I’m pleased to say that hospices have become quite liberal in their interpretation of primary caregiver availability. As long as there’s a safety plan in circumstances in which patients are no longer safe living alone. So whereas in the past, it often meant that somebody needed to be living with that patient 24/7, now if there’s an appropriate backup plan, it requires access to a caregiver, but not necessarily one that lives with the patient. So, a backup plan might be moving to an assisted living facility, moving in with a --- a family or friends or perhaps going to a nursing home. And hospice care would then continue in those locations.

续时间可以远远超过六个月，只要他们满足相关的标准。标准要求患者接受无治疗目的的服务，而且要求患者有主要的照护者。但令人欣喜的是，临终关怀机构对主要照护者的解读已经放宽了许多。当患者不再能够安全地独自生活时，只要有一套安全计划即可。在过去，这意味着必须有人全天与患者同住，而现在，如果有恰当的后援计划即可，要求在必要时照料者可以前来，但不必与患者同住。所以，后援计划可以是搬到辅助式养老院，或搬去与家人或朋友同住，或者搬到护理院。然后可以在这些地点继续提供临终关怀护理。


• Nurse

• Home health attendant

• Physician (limited)

• Social work

• Chaplaincy

• PT/OT/ST/dietician

• Volunteer

• Bereavement care

• Medications related to qualifying dx

• Durable medical equipment

Hospice: Available Services

Now, in contrast to skilled nursing care, which is a fee-for-service program, and services are recommended by the physician, hospice is mandated to have this whole menu of services, so it requires nursing care. And the nurse is really the --- the --- plays a very primary role --- in the care here; home health attendant to help with personal care needs; physician involvement, which is somewhat less intense than in the outpatient setting; social work; chaplaincy; physical, occupational, speech therapy; dietitian; volunteer care; bereavement care for the family; medications requated --- related to the qualifying diagnosis. So, for example, if you have a patient with cancer, and they require medication for cancer-associated pain, that would be covered, but if they had hypertension before developing cancer, so unrelated to the cancer, those medications would not be picked up by cancer --- by the hospice team. But the hospice provides all medications related to the qualifying diagnosis. And they also provide durable medical

由医生建议的专业护理照护是按服务收取费用。临终关怀与之不同，是强制性整套服务，所以要求有护士的护理。而护士在临终关怀照护中起到主要的作用；居家保健护理员帮助满足个人护理需求；医生的参与在某种程度上要少于门诊时的参与程度；社工；牧师；理疗、职业治疗、语言治疗师；营养师；志愿者的照护；对家人的哀丧照护；合理诊断的相关药物。例如，如果一位癌症患者有癌症相关的疼痛，临终关怀团队会提供止痛药物，但如果患者在发生癌症之前就有高血压，因而与癌症无关，那么临终关怀团队不会提供高血压药物。但临终关怀会提供合理诊断的所有相关药物。他们还会提供耐用性医疗器械。所以有些方面常常可能需要由居家护理的服务人员另行提

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equipment. So these are things that might often need to be picked up separately for somebody on home care.

供。


• Routine Home Care

• Continuous Home Care

• Inpatient Respite Care

• General Inpatient Care

$142.91

$834.10

$147.83

$635.74

2010 Medicare Levels of Hospice Care: Per Diem National Reimbursement Rates

(geographic variation) www.cms.hhs.gov/mlnproducts/downloads/hospice_pay_sys_fs.pdf

Now, hospice, in contrast to home care, which is fee-for-service, is paid on a per diem basis. So, every day that hospice provider gets a flat rate no matter what care they provide. So, that per diem rate covers the nursing visit. It covers home care. It covers chaplaincy, whatever disciplines go out that particular day to see the patient. It covers all the medications related to the qualifying diagnosis, any needed equipment, etc. And it all has to come out of that flat rate. And while these are national averages, there’s geographic variation, you can see that in our current healthcare climate, these aren’t very high rates. So, for people on the --- the routine home care rate, which is the majority of patients, that rate is approximately $140 per day. So, you can see why, if patients were undergoing daily blood tests or perhaps diagnostic MRIs, that reimbursement would be rapidly used up and, if the pat --- if the hospice isn’t fiscally conscious, they wouldn’t be able to provide care of the rest of their patients. And that’s why there needs to be a thoughtful approach, so that the patient receives what benefits them, but doesn’t get other things that are unlikely to alter their cost and that would preclude appropriate hospice care. On the continuous home care rate, which can happen for brief periods at a time, where more intense nursing home care can be put in, so instead of the nurse coming back and forth to visit every few days or whatever is deemed to be appropriate, on continuous home care, nursing care can be put in the home on a --- up to a 24-hour basis usually for about up to three days or so at a time. The rate is about $834 a day. And, of course, that’s prorated based on the number of hours the nurse is in the home. So, this is basically to tide somebody over a symptom crisis that otherwise would require inpatient management. Inpatient respite

与按服务收取费用的居家护理不同，临终关怀是按日收费。所以，无论临终关怀服务提供者提供何种服务，他们每天都获得一笔固定的费用。每日费用包括护士家访、居家照护、牧师服务（无论哪一类宗教的服务人员当天去看望了患者）、与合乎要求的诊断相关的所有药物、所有需要的器具等。固定费用里面必须包括所有这些。这些是全国平均金额，而各地区水平会有异同。大家可以看到，在目前的医疗保健环境下，这些金额并不算很高。大部分患者接受的常规居家护理，其费用大约是每天 140 美元。大家可以看到，如果患者每天都验血或做诊断性 MRI，报销金额很快就会用尽。假如临终关怀机构在财务上不注意的话，就无法为其他患者提供服务。所以需要谨慎行事，既要让患者得到有帮助的服务，又要避免提供可能会改变费用水平且阻碍患者获得恰当临终关怀护理的其他服务。持续性居家照护是更为密集的护理居家照护，每次提供的持续时间较短。在持续性居家照护时，护士不是每隔几天或每隔恰当的时间往返一次，而是连续在家中提供照护，最长可达每天 24 小时，每次通常最长可持续三天。持续性居家照护的费用是每天 834 美元。当然实际收取的费用是根据护士在家中提供服务的小时数计算的。基本上来讲，这种服务

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care is provided in the hos --- general inpatient care is provided in the hospice’s inpatient setting. And that location may vary depending on the particular hospice provider. Some have free-standing buildings that they use; that are their own. Others may rent space, if you will, either from a hospital or a nursing facility. So, where that location is may vary, but, in general, for people who are having a symptom crisis they can then move to the inpatient level of care and, just like for a hospital, the individual stays there until that symptom need resolves. So, it’s for a self-limited period of time. You can see that rate is a little over $600 per day, the average national. And again keep in mind that 80% of the aggregate care that a hospice provides in a particular benefit period needs to be in the home setting or they’re actually subject to fairly big fines. And you can see why people can’t stay in the general inpatient setting indefinitely, because, by definition, less than 20% can happen not for an individual patient, but for the aggregate in the inpatient setting. Respite care is a little bit different, inpatient respite care. That’s for people whose symptoms are under good control and would otherwise be in the home setting, but perhaps their caregivers are going out of town for a family wedding or what have you. So, the patient can move to the inpatient respite setting for a brief period of time. And that’s reimbursed fairly similarly to the routine home care rate.

是帮助患者度过症状危象，否则患者需要入院管理。一般住院护理是在临终关怀机构的住院部提供的。具体地点根据具体临终关怀提供者的情况而可能有所不同。某些临终关怀机构可以使用自己拥有的独立建筑物。有些则可能是从医院或疗养院租赁床位。所以具体地点可能有所不同，但一般而言，出现症状危象的患者可以转而接受类似医院的住院级别的护理，直至症状消除。所以接受这项服务的时间有限。可以看见这项服务的全国平均费用水平略微超过每天 600 美元。要注意的是，如前所述，一家临终关怀机构在特定福利时间内，总体护理中有 80% 需要在家中提供，否则他们会受到金额颇高的罚款。这样就可以理解为何患者不能无限期地留在一般住院设施中，因为按照定义，不到 20% 这一数字并不是针对具体某位患者，而是针对整个住院设施。住院暂替护理略有不同。患者的症状控制情况良好，本可以留在家中，但是可能他的照护者到外地去参加家族中的婚礼去了等等，因此患者就可以在短时间内接受住院暂替服务。这项服务的报销金额类似于常规居家护理费率。

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Palliative Care Model at UT MD Anderson Cancer Center: “Simultaneous Care”

Palliative Care

Consult Service

Palliative

Care

Inpatient Unit

Palliative Care

Outpatient Clinic

Primary

Service

Hospice

Inpatient Nursing

Units, ER, ICU

Okay, now looking at how palliative care can be integrated with traditional medical care, you can see the model that we use at The University of Texas MD Anderson Cancer Center and this is called “Simultaneous Care”. So, people are seen by their primary service. For people who are outpatients, we follow them up in our outpatient clinic. When people are hospitalized, we see them as part of our consultation service whether they’re in the inpatient nursing unit, emergency center, intensive care unit. For patients with more complex care needs, they may be transferred to our acute palliative care unit where we would take the primary role in their care at that point and their primary service of origin would be available to consult as needed. And then depending on their needs, they would either be discharged home where we would follow up in the outpatient clinic. They may be getting more chemotherapy or, for those patients who are no longer benefitting from chemotherapy, after discussion with the patient, family, and primary team, they may be discharged with hospice care. So, you can see that it’s a very energetic process, if you will, where people can go back and forth in the different aspects of our program depending on what suits their care needs best.

现在让我们来看看姑息性护理整合进入传统医学护理的方式。这里是我们德克萨斯大学 MD Anderson 癌症中心使用的名为“同时护理”的模型。患者前往其基础保健服务提供者就诊。门诊患者，我们在门诊诊所追踪其情况。入院患者，无论是在住院护理病房、急诊室还是重症监护室，我们在会诊服务时为其看诊。对于病情更为复杂的患者，可能会将其转入我们的急性姑息性护理病房。主要由我们在这里为其提供护理，而其起始基础保健服务会按需提供会诊服务。然后根据患者的具体需要，或者出院返家，而我们会在门诊诊所追踪他们的情况，或者接受更多化疗。对于化疗不再有效的患者，在与患者、家人和基础护理团队商谈之后，可以让他们出院，接受临终关怀护理。大家能够看到，这可以说是个颇为活跃的过程，患者可往返于我们计划的不同部分，以便最好地满足其照护需求。

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Models of Palliative Care in the Models of Palliative Care in the Models of Palliative Care in the Models of Palliative Care in the United States: SummaryUnited States: SummaryUnited States: SummaryUnited States: Summary

• Hospital-based: primary, secondary and tertiary levels of care, depending on level of expertise available, services provided and presence of research and educational programs

• Community-based includes outpatient visits, traditional home care or hospice care

• Hospice is a concept of care that focuses on quality of life for patients with a life expectancy of < 6 months who are no longer receiving curative therapy; typically provided in the home

• Ideally, palliative care is based on “simultaneous care”throughout the disease trajectory

Okay, so, in sum, hospital-based primary --- palliative care can be practiced at the primary, secondary, or tertiary level depending on the patient’s needs and the type of expertise available in the community of that particular patient. Tertiary palliative care, in addition to treating patients with the most complex care needs, also requires the presence of research and educational programs. Educational programs not only in terms of continuing education, but, for example, fellowship programs, programs for the community --- lay community, and then the research component. Community-based options include outpatient visits, traditional home care, or hospice care. Hospice itself is a concept of care and not a location for patients with a life expectancy of six months or less, assuming the disease runs its anticipated course, patients who are no longer receiving curative therapy, and is typically provided in the home care setting. And ideally palliative care is based on simultaneous care throughout the disease trajectory, so that patients have access to the type of care that suits their needs best at that point in the disease continuum. Thank you very much for listening to me. I hope this has cleared up some areas of fogginess for you. And we’d really appreciate your feedback on this presentation, so that in future iterations we can be even more effective. Thank you.

总而言之，根据患者的需要和患者所在社区可供使用的专业经验类型，可以做主要、次要或三级护理水平提供姑息性护理。三级姑息性护理除了治疗患者最为复杂的护理需要，还需要有研究和教育计划。教育计划不仅是指继续教育，还指例如专科受训计划、针对公众社区的计划和研究组成部分。社区选项包括门诊就诊、传统居家护理或临终关怀护理。临终关怀本身是疾病按预期进展时寿命不超过六个月的患者接受护理的一种概念，而不是接受护理的地点；这些患者不再接受治愈性治疗，而且通常在家中接受护理。理想情况下，应该在疾病整个发展轨迹中根据同时护理模型提供姑息性护理，这样患者就可以在疾病连续发展过程中，使用最适合其需要的护理类型。非常感谢各位参加我的讲座。我希望本次讲座回答了大家的疑问。我们非常希望各位就本次讲座提供反馈意见，以便我们提高以后讲座的效率。谢谢。

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PPt Donna Zhukovsky- Palliative Care, Part 3- MC-CH · PDF file1 PowerPoint Slides English Text Mandarin Chinese Translation Palliative Care, Part 3 VideoTranscript 3 Professional